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February 24, 2013

I Am Taking a Reflux Medication & My Symptoms are Not Improving!

On an almost daily basis, I get an email from somebody with the same exact question or near-variation:
"Dear Dr. Chang,  I have been taking a [insert reflux medication] for [insert number] weeks and I see no improvement in my [insert symptom]. What should I do?"
The reflux medication typically mentioned include nexium, dexilant, prilosec, prevacid, protonix, or some other proton pump inhibitor.

The most common symptoms typically mentioned include:

Globus
Cough

What Should You Do?

Well, assuming you never have taken a reflux medication in the past, proton pump inhibitors work extremely well in suppressing acid; even at low dosages.

As such, if you indeed have been taking a proton pump inhibitor for at least 3 weeks and see no improvement in symptoms, one must consider the possibility that acid reflux may not be the problem.

I rarely if ever just increase the dosage of a reflux medication in somebody who previously was never on one. Increasing the medication dosage MIGHT be considered only if somebody has already been on reflux medication for some time baseline.

So if acid reflux is not the problem, what may be causing above-mentioned symptoms?



There could be an anatomic problem...

• Cricopharyngeal spasms/hypertrophy
• Esophageal dysmotility
etc

Essentially, there's something wrong with your swallowing tube such that things back up into the throat causing symptoms. Think of it like a clogged sink... the pipe (esophagus) has a physical issue that causes water to backup into the sink (throat).

Workup to evaluate these possibilities include trans-nasal endoscopy, EGD, barium swallow, and/or manometry.

It could still be a reflux problem...

Just maybe, it's NOT acid reflux however, but mucus or non-acid reflux. Standard reflux medications do not work for non-acid reflux. The best way to evaluate this possibility is to undergo a 24 hour multichannel pH and impedance testing. Of note, BRAVO or pH monitoring alone is NOT good enough. Impedance must be measured as well as having sensors near the throat level.

In the meantime, one could also try avoiding eating anything that contains dairy, egg, and wheat (flour). These foods are considered highly mucogenic (most people can relate to the fact that when drinking too much milk, the mouth and throat can get phlegmy).

Is it allergy?

Post-nasal drainage can sometimes lead to throat symptoms. If you do have some sino-nasal allergies, try taking a steroid nasal spray and an anti-histamine nasal spray. Oral medications typically do not work as well.

There's also a condition known a eosinophilic esophagitis that can cause throat symptoms. The only way to diagnose this condition is an upper endoscopy (EGD) with biopsies of the esophageal lining.



Summary

Now this article just scratches the surface in FULLY addressing an individual patient's throat symptoms. After all, not everybody is exactly the same. For a more in-depth evaluation and individualized treatment of YOUR throat issues, please make an appointment with your ENT.

Here are some related articles that may be helpful:

Fauquier blog
Fauquier ENT

Dr. Christopher Chang is a private practice otolaryngology, head & neck surgeon specializing in the treatment of problems related to the ear, nose, and throat. Located in Warrenton, VA about 45 minutes west of Washington DC, he also provides inhalant allergy testing/treatment, hearing tests, and dispenses hearing aids. Google+ Christopher Chang, MD Bio

1 comment:

  1. I have been diagnosed with eosinophilic esophagitis after much work-up including initial denial that I even had it. The problem is that now after much attention being paid to me and my GI problems, almost no attention is being paid to me even after diagnosis of H-pylori to boot. I think omeprazole is good for standard GI sufferers that have typical reflux and acid, but methinks mine is different obviously. Omeprazole dries me out completely, my throat, et al. I wish they would do that impedance test on me, but I don't think it's part of their 'system' as if EGDs are the only thing that is pertinent. More confusion.

    ReplyDelete

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